"During a fire inspection activity involving inspection of fire walls that serve as Appendix R barriers, degradation of some fire walls was identified that was sufficient to prevent these walls from meeting Appendix R requirements as 3-hour fire barriers. In the event of a postulated fire in the affected areas, both safe shutdown paths on the affected unit could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded conditions can be corrected.

"Condition Reports: 850802, 850819"

In addition to automatic fire protection features, the licensee has posted fire watches as a compensatory measure.

"As part of the 'extent of condition' corrective action for the condition identified in EN 50351, an inspection activity is in progress to inspect the remaining fire walls for conditions similar to those reported on 8/7/2014. During this inspection, another condition was identified involving some degradation of the fire wall between Fire Area 1023 - RPS MG Set Room and Fire Area 1015 - Annunciator Room. In the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS update report and will be documented in a revised LER at the end of the inspection activity.

"As part of the 'extent of condition' corrective action for the condition identified in EN 50351, an inspection activity is in progress to inspect the remaining fire walls for conditions similar to those reported on 8/7/2014. During this inspection, another condition was identified involving some degradation of the fire wall between Fire Area 1016 - 600 Volt Switchgear Room 1C and Fire Area 1017 - 600 Volt Switchgear Room 1D. In the event of a postulated fire in the affected areas, both safe shutdown paths on Unit 1 could be compromised. Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS update report and will be documented in a revised LER at the end of the inspection activity."

"As part of the 'extent of condition' corrective action for the condition identified in EN 50351, an inspection activity is in progress to inspect the remaining fire walls for conditions similar to those reported on 8/7/2014. During this inspection, additional conditions were identified involving multiple fire barriers in the control building that affected both safe shutdown paths on Unit 1 and Unit 2 based on the respective inspection results. In the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 and 2 could be compromised.

"Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B). Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS update report as required and will be documented in a revised LER at the end of the inspection activity."

"As part of the 'extent of condition' corrective action for the condition identified in EN# 50351, an inspection activity is in progress to inspect the remaining fire walls and associated penetrations for conditions similar to those reported on 08/07/2014. During this inspection, nonconformances of multiple fire barriers were identified that bring into question the functionality of the affected fire barriers that can compromise safe shutdown paths on Unit 1 and 2 based on the respective inspection results. Since additional time is required to further evaluate each nonconformance to conclusively determine if the nonconformance is sufficient to consider the barrier nonfunctional, interim conservative fire actions were taken by considering these fire barriers as nonfunctional. Based on this conservative conclusion, in the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 and 2 could be compromised. Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded penetrations and fire walls in most of these same fire areas and will remain in place until the barrier(s) are repaired. Additional fire actions were taken as required to address the additional fire areas identified. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report and will be documented in a revised LER at the end of the inspection activity.

"As part of the 'extent of condition' corrective action for the conditions identified in EN# 50351, an inspection activity was performed of a fire wall for conditions similar to those reported on 12/12/2014. During this inspection, another condition was identified involving some degradation of the fire wall between Fire Area 1008 - Unit 1 AC Inverter Room and Fire Area 0001 to consider the barrier nonfunctional. In the event of a postulated fire in the affected areas both safe shutdown paths on Unit 1 could be compromised. Given this information the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded fire barriers in these same fire areas and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. The inspection activity is continuing and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report and will be documented in a revised LER at the end of the inspection activity."

"During review and closeout of fire barrier and penetration seals work orders and surveillance procedures performed as part of the 'extent of condition' inspection activity initially described in Event # 50351, the following conditions were identified that in the event of a postulated fire in the respective fire areas listed both safe shutdown paths could be compromised.

"Given this information the determination was made that this condition meets the reporting criteria of 10 CFR 50.72(b)(3)(ii)(B). Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded fire barriers in the Unit 2 fire area and will remain in place until the affected barrier areas are repaired. Compensatory measures were established for the Unit 1 areas and will remain in place until the affected barriers areas are repaired. The presence of the compensatory measures in addition to automatic fire detection in these fire areas ensure that the safe shutdown paths are preserved until the degraded condition is repaired. Subsequent similar condition(s) found when performing remaining inspections that meet the reporting requirements will be included in an ENS Update Report and will be documented in a revised LER at the end of the inspection activity.

"During the review of fire barrier surveillance procedures performed as part of the 'extent of condition' inspection activity for the event initially identified in EN# 50351, some degradation was observed on the east wall of fire area 2006. These nonconforming issues observed on the affected fire wall were identified as affecting both safe shutdown paths for Unit 2. Therefore, in the event of a postulated fire for the affected area, both safe shutdown paths on Unit 2 could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire area and will remain in place until the wall is repaired. The presence of the compensatory measures, in addition to portable fire protection equipment located in adjacent areas, ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The extent of condition inspection activity is continuing, and this, and any subsequent similar condition(s) that meets the reporting requirements, will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity."

"During performance of work package closeouts to support the 'extent of condition' inspection activity for the event initially identified in EN# 50351, the following fire barriers were identified as failing to meet the procedure acceptance criteria:
- Three penetrations separating Unit 1 Fire Areas 1013 and 0040
- A fire wall deficiency in the wall separating Unit 1 Fire Areas 1015 and 1013

"These nonconforming issues observed on the affected penetrations and fire wall were identified as affecting both safe shutdown paths for Unit 1. Therefore, in the event of a postulated fire for the affected area, both safe shutdown paths on Unit 1 could be compromised. Given this information, the determination was made that this condition meets the reporting criteria of 10CFR50.72(b)(3)(ii)(B).

"Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire area and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The extent of condition inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity.

"During the review and closeout of a work package performed as part of the 'extent of condition' for the inspection activity initially described in EN #50351, a fire penetration seal was identified as failing to meet the procedure acceptance criteria. This penetration seal is located in the 2C Diesel Generator (DG) room and passes between Fire Area 2407 and 2408.

"The nonconforming issue observed on the affected penetration was identified as affecting both safe shutdown paths for Unit 2. Compensatory measures were established for the Unit 2 Areas and will remain in place until the affected barriers areas are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The extent of condition inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity.

"During an expanded scope inspection, two deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:
- Small imperfections and a hole through Penetration 1Z43-H116C that passes between Fire Area 1101G (Unit 1 Reactor Building Closed Cooling Water (RBCCW) Room) and Fire Area 1006 (Unit 1 Water Analysis Room), and
- Gaps in a civil/architectural joint at the top of the south wall leading from Fire Area 1006 (Unit 1 Water Analysis Room) to Fire Area 0007A (East Corridor in the Control Bldg.).

"These nonconforming conditions observed for the affected penetration and fire barrier were identified as affecting both safe shutdown paths for Unit 1. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire area and will remain in place until the wall is repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The expanded scope inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS update report as required and will be documented in a revised LER at the end of the inspection activity.

"CR 10035730"

The licensee will be notifying the NRC Resident Inspector. Notified R2DO (Sykes).

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:
- Imperfections in three penetration seals (2Z43-H037C, 2Z43-H038C, and 2Z43-H177C) located in the 2A Battery Room separating Unit 2 Fire Areas 2004 and 2005
- Imperfections in fire penetration seal 2Z43-H644C located in the U2 Water Analysis Room separating Fire Area 2006 and 0007A
- Imperfections in the grout between two tiers of concrete masonry wall and at the intersection of the walls in the upper northeast corner of the U2 Water Analysis Room separating Fire Areas 2006 and 0007A

"The nonconforming conditions observed for the affected penetrations and fire barriers were identified as affecting both safe shutdown paths for Unit 2. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until the fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The expanded scope inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity.

"During an expanded scope inspection, a fire penetration seal was observed to contain imperfections that did not meet acceptance criteria. Penetration seal 1Z43H542C is located between the U1 Corridor, Fire Area 0001, and the Unit 1 AC Inverter Room, Fire Area 1008, in the Unit 1 Control Building.

"The nonconforming issue observed on the affected penetration was identified as affecting both safe shutdown paths for Unit 1. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until all associated non-functional fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The extent of condition inspection activity is continuing and this, and any subsequent similar condition(s) that meets the reporting requirements, will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity.

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:

- Gap in the concrete masonry wall at penetration seal 1Z43-H547C located between the Unit 1 AC Inverter Room (Fire Area 1008) and the Unit 1 Corridor (Fire Area 0001)
- Gap in the annulus around the 2 inch continuous run penetration seal located between the Unit 1 AC Inverter Room (Fire Area 1008) and the Unit 1 Corridor (Fire Area 0001)
- Gap in penetration seal 1Z43-H059C located between the Unit 1 AC Inverter Room (Fire Area 1008) and the Unit 1 Corridor (Fire Area 0001)

"The nonconforming conditions observed for the affected penetrations and barrier were identified as affecting both safe shutdown paths for Unit 1. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until the fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The expanded scope inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity.

"During an expanded scope inspection, a fire wall was observed to contain a gap behind a 3 inch square plate attached to the thru-bolt anchor that did not meet acceptance criteria and caused the affected barrier to be considered nonfunctional. The affected fire barrier is located between the U2 RPS MG Set Room (Fire Area 2013) and the U2 Annunciator Room (Fire Area 2015).

"The nonconforming issue observed on the affected fire barrier was identified as affecting both safe shutdown paths for Unit 2. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until all associated non-functional fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The extent of condition inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity.

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:

- Gap around penetration 1Z43H805D located between the Unit 1 East DC Switchgear Room 1D (Fire Area 1017) and the Unit 1 Transformer Room (Fire Area 1019).
- Gaps in a fire barrier around a unistrut, below penetration 1Z43H012D, that are approximately 7 deep and into the CMU core located between the Unit 1 East DC Switchgear Room 1B (Fire Area 1020) and the Unit 1 130' Elevation Control Building Working Floor Hallway (Fire Area 0014K)
- Gap in the top corner of the wall, above 1Z43H842D that protrudes into the CMU approximately 7 deep located between the Unit 1 East DC Switchgear Room 1B (Fire Area 1020) and the Unit 1 130' Elevation Control Building Working Floor Hallway (Fire Area 0014K)
- Two anchor bolt holes east of penetration 1Z43H810D located between the Unit 1 East DC Switchgear Room 1B (Fire Area 1020) and the Unit 1 East DC Switchgear Room 1D (Fire Area 1017)

"The nonconforming conditions observed for the affected penetrations and fire barriers were identified as affecting both safe shutdown paths for Unit 1. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until the fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The expanded scope inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity."

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:

- A 1/16" wide x 4" long x 5" deep gap was identified at the top of the wall, above penetration 1Z43H646D, in the west wall in Unit 1 East 600V Switchgear Room (separating Fire Area 1017 and Fire Area 1016).

- A 1/16" wide x 4" long x 7" deep gap was identified at the top of the wall, above penetration 1Z43H646D, in the east wall in the Unit 1 West 600V Switchgear Room (separating Fire Area 1016 and Fire Area 1017).

- A «" wide x 2" long x 7" deep gap was identified at the top of penetration 1Z43H522D located between the Unit 1 West 600 V Switchgear Room (Fire Area 1016) and U1 East 600 V Switchgear Room (Fire Area 1017).

"The nonconforming conditions observed for the affected penetrations and fire barriers were identified as affecting both safe shutdown paths for Unit 1. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until the fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The expanded scope inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity.

"CR 10055316; CR 10055377"

The licensee will notify the NRC Resident Inspector. Notified the R2DO (Bartley).

"During an expanded scope inspection, deficiencies in the following areas were observed that caused the affected barriers to be considered nonfunctional:

- A 1" wide x 2" long x 7" deep gap was identified at the top of penetration 1Z43H622D in the west wall of the Unit 1 RPS MG Set Room (separating Fire Area 1013 and Fire Area 0014K).

- A 1/4" wide x 1/4" long x 7" deep gap was identified near a ground wire, above penetration 1Z43H595D, at the top of the east wall of the Unit 1 East DC Switchgear Room (separating Fire Area 1020 and Fire Area 1104).

- A 3" wide x 1/4" tall x 7" deep gap was identified at penetration 1Z43H617D on the south wall of the Unit 1 Working Floor (separating Fire Area 0014K and Fire Area 1013).

"The nonconforming conditions observed for the affected penetrations and fire barriers were identified as affecting both safe shutdown paths for Unit 1. Compensatory measures were already in place in accordance with the plant's Fire Hazard Analysis (FHA) as a result of previous conditions involving degraded barriers in the same fire areas and will remain in place until the fire barriers are repaired. The presence of the compensatory measures in addition to portable fire protection equipment located in adjacent areas ensures the safe shutdown paths are preserved until the degraded conditions are repaired. The expanded scope inspection activity is continuing, and this and any subsequent similar condition(s) that meets the reporting requirements will be included in an ENS Update Report as required and will be documented in a revised LER at the end of the inspection activity.

"CR 10056548; CR 10056555; CR 10056582"

The licensee will notify the NRC Resident Inspector.

Notified the R2DO (Bartley).

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!

"Cooper Nuclear Station became aware of the installation of two 12,000 gallon anhydrous ammonia tanks approximately 1.5 miles from the site. This amount of anhydrous ammonia at that distance exceeds the control room habitability hazardous chemical analysis previously evaluated for the nuclear station. The control room staff has been informed of the condition and have reviewed the appropriate abnormal procedures for actions to take in the case of a leak. This potentially represents an unanalyzed condition that significantly degrades plant safety and is reportable under 10 CFR 50.72(b)(3)(ii)(B)."

"Subsequently it was determined that the Control Room Habitability Analysis that was performed in response to the NRC's post-TMI requirements bounds the identified condition. This analysis includes the potential of a toxic chemical leak from a 725-ton tank on a river barge carrying anhydrous ammonia. The volume of chemical, and distance from the control room, included in the post-TMI habitability analysis bounds the conditions found with the newly constructed anhydrous ammonia tanks."

"On April 4,2015, at approximately 1151 [EDT], a chemical reaction occurred in a 2-liter bottle of cleanup materials. The bottle was located in a storage rack. The chemical reaction caused the bottle to breach, releasing some of the contents into the immediate area around the storage rack. There were no individuals in the area where the bottle was stored when the breach occurred. The area has been roped off and is in the process of being cleaned up. There were no personnel injuries or exposures. The event is currently being investigated.

The following was received from the Commonwealth of Kentucky via email:

"On 19 March 2015, the patient was receiving an HDR cylinder treatment using the HDR Ir-192 source for treatment of her vaginal cuff. The prescribing physician inserted the vaginal cylinder in the patient's vagina until resistance was present, indicating the tip of the cylinder had reached the vaginal cuff. Before each treatment is delivered a radiographic image of the inserted treatment device is reviewed to ensure consistent device location across each fraction (this image is not intended as a placement verification for treatment). Comparison of images taken on 19 March 2015 and 12 March 2015, revealed that the cylinder placement during treatment on 12 March 2015, was 3cm distal to the cylinder placement on 19 March 2015, implying the dose delivered during the patient's first treatment on 12 March 2015 was located 3cm distal to its intended location. The effect of relocating the cylinder to a 3cm distal position has the effect of under dosing the vaginal cuff, while providing additional dose to the vaginal wall in an unintended location. The RHB [Kentucky Radiation Health Branch] has requested additional dose information to the vaginal wall area. Some of the vaginal wall is dosed during this procedure just not in this location. The prescribing physician has deemed the additional dose to the vaginal wall as medically insignificant. Vaginal cuff treatments are planned to deliver a prescribed dose to a reference line located 0.5cm outside the cylinder wall. A new treatment plan depicting the true location of the 12 March 2015, treatment has been generated and a comparison of the dose to the reference line has been made to estimate the extent to which the vaginal cuff has been under dosed. The average dose delivered to the vaginal cuff area was 80% lower than intended. Due to the fact that the dose to the vaginal cuff from the first treatment is so low, the physician has decided to ignore the patient's first treatment and change the patient's prescription to deliver the intended dose over the remaining fractions. The authorized user notified the patient upon completion of her treatment on 19 March 2015. Two possible scenarios have been determined to be the most likely cause of the event:

"1. The first is that the cylinders used for treatment are segmented. Typically 4 segments are locked together into one larger cylinder. The larger cylinder is then attached to a clamping device that allows the cylinder to be locked into position after the authorized user (AU) inserts the device into the patient. During this particular treatment only 3 segments were used to form the cylinder leaving less space for the clamping device to attach to the cylinder. As the AU was inserting the cylinder, the cylinder clamping device may have pushed up against the patient's perineum prematurely causing resistance to further insertion prompting the AU to believe the cylinder had reached the vaginal cuff.

"a. In order to prevent future occurrences from happening, the staff involved will be required to always use all 4 segments when constructing a cylinder.

"2. The other possibility is due to the non-compliance of the patient herself. As the cylinder was being inserted, the patient was having a hard time remaining still. Once the cylinder was locked into place, it is possible that the patient pulled away from the cylinder a small amount causing the change in location. This is believed to be the most likely scenario based on the patient's common reaction and motion upon insertion of the cylinder.

"a. In order to minimize a patient's ability to adjust the cylinder position, staff will be instructed to pay close attention to the patient's movements and additional imaging of the device location will be taken if movement is a concern. A phone call was made to the KY Radiation Health Branch of the incident with intent to meet the notification requirements to the KY RHB. The Physicist had left a phone message but did not report to a person. There is no record of this message however a record of a phone call is noted received 19 March 2015 at 1450 EDT. Upon receipt of an email to the Radiation office, the required 24 hour notification is made to the NRC Headquarters Operations Officer."

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

The following information was received from the State of Texas via email:

"On April 8, 2015, the Agency [Texas Department of State Health Services] was notified by the licensee's site radiation safety officer (RSO) of a source disconnect. The RSO stated a radiography crew had contacted him [from a field site in Charco, TX] and informed him that after the first exposure of a 62.2 curie Iridium - 192 source, they could not retract the source back into a QSA 880D exposure device. The RSO stated he arrived at the site and found dose rates at the boundaries to be less than 0.5 millirem per hour. The RSO, who is on the license to retrieve a source, detached the guide tube from the camera and using a pair of tongs, lifted the collimator and the source slid out on the ground. The RSO placed bags of lead over the source. The RSO cranked the drive cable through the camera and connected the drive cable to the source. The RSO then retracted the source into the camera locking it in place. The RSO stated he inspected the camera and crankout device in the field and could not find any cause for the disconnect. The maximum dose during the event was received by the RSO who received 24 millirem to his hand and 16 millirem to his chest.

"No member of the general public was exposed as a result of this event.

"Additional information will be provided as it is received in accordance with SA-300."

"On April 9, 2015, a NOG-L [Nuclear Operations Group - Lynchburg] employee passed away shortly after arriving to work. The employee arrived to work at 0534 [EST]. He proceeded to his work center and collapsed at 0540 while clocking in. CPR was administered to the employee by a co-worker who was at the scene and the site Emergency Team was called. The Emergency Team arrived in three minutes and used an AED to attempt to resuscitate the employee. At 0555, the Emergency Team transported the employee in our onsite Advanced Life Support ambulance to Lynchburg General Hospital (arrived 0623). CPR was maintained in transit to the hospital. The employee was pronounced dead at the hospital from an apparent heart attack.

"NOG-L reported this event to the Occupational Safety and Health Administration (OSHA) at 1110 on April 9, 2015."

The Licensee notified the NRC Resident Inspector and will notify the NRC Regional Office.

"The RSO for Georgia-Pacific Corporation, Palatka, Florida called to report a fixed Cesium-137 source installed on a tank has the shutter stuck open. The device is 936 mCi [Cesium-137], Kay-Ray Sensall Model 7063P. It is located in the overhead in an isolated area.

"They were in the process of conducting an inspection and leak test of the device when it was discovered. The last time the shutter was cycled was last year. The RSO reports there is no over exposure of personnel, no leaks. The location of device prohibits access to personnel so there is no chance of accidental exposure.

"The area has been posted and a work order has been submitted to replace/repair the device."

"On April 16, 2015, Byron Station will remove part of the Technical Support Center (TSC) emergency ventilation system from service to facilitate necessary surveillance work on the fire protection system. This work is expected to last approximately 4 hours. This maintenance affects the ability of the TSC ventilation to maintain adequate habitability during the duration of an emergency. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. If the TSC becomes uninhabitable, the Station Emergency Director will relocate the TSC staff to an alternate TSC location in accordance with applicable procedures.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to the potential loss of an emergency response facility because of the unavailability of the ventilation system. An update will be provided once the TSC ventilation has been restored to normal operation."

"At 1320 CDT, on April 16, 2015, both doors of a Secondary Containment Airlock were reported to be open. The doors being open at the same time caused a failure to meet SR 3.6.4.1.2 to verify that either the outer door(s) or inner door(s) in each Secondary Containment access opening are closed. The identified condition caused Secondary Containment to be considered inoperable per TS LCO 3.6.4.1. Upon discovery, immediate action was taken to close the doors. The doors were open concurrently for a momentary amount of time. The action to close the door allowed SR 3.6.4.1.2 to be met, and restored Secondary Containment to an operable status.

"The notification is being made pursuant to 10 CFR 50.72(b)(3)(v)(C).

"The NRC Resident Inspector has been notified."

The licensee is investigating how the electrical interlock failed to prevent this occurrence.